Aetna Medicare Rx Essentials
Aetna Website
Exception/Prior Authorization Form
Aetna Formulary Search Tool
Directions:
Step 1: Click on Medicare Plans
Step 2: Choose Three Tier Open Formulary
Step 3: Click on “Medicare Medication Search”
Step 4: Begin Searching by Drug or Therapeutic Class
Prior Authorization Line: 1-800-414-2386
Customer Service: 1-800-529-5586
Members: 1-877-238-6211
back to top of page
Anthem
Anthem Website
To access Prior Authorization forms:
Go here, then follow these steps:
Click providers
Click physician PAB forms
Login as (caps sensitive) User: ANTHEM2 Password: ANTHEM3
Click Clinical Services
Click Reports and Publications
Click Med D Prior Auth Benefit Forms
Formulary Search Tool
Prior Authorization Line: 1-800-338-6180
Customer Service Line: 1-866-244-1241
Member Services: 1-866-755-2776
back to top of page
Cigna Medicare Rx (Plan One, Plan Two Enhanced)
Cigna Website
Cigna Formulary Search Tool (For .pdf versions of Plan One and Plan Two, follow links.)
Standard Forms
Coverage Determination Form
Prior Authorization: 1-800-558-9363
Customer Service: 1-800-735-1459
Members: 1-800-222-6700
back to top of page
First Health Premier
First Health Premier Website
Providers Website
2009
Premier Comprehensive Formulary(.pdf)
Formulary Search Tool
Forms:
Standard Form
Coverage Determination, Prior Authorization, Appeals and Grievance Procedures Forms
Prior Authorizations (Urgent Requests Only): 1-800-551-2694
Exceptions / Prior Authorizations Fax: 1-800-639-9158
Customer Service: 1-800-588-3322
Members: 1-866-865-0662
back to top of page
Coventry Advantra Rx
Coventry Advantra Website
Formulary Search Tool
Prior Authorization Form
Drug Specific Prior Authorization Forms
Quantity Limit Exception Form Link
Prior Authorization Line: (800) 551-2694
Prior Authorization Fax: 1-800-639-9158
Customer Service Line: 1-800-882-3822
Appeals and Grievance Line: 1-800-536-6167
Appeals and Grievance Fax: 1-800-535-4047
back to top of page
Health Net (Orange Option 1 and 2)
Health Net Website
Comprehensive Formulary (.pdf)
Prior Authorization Form
Prior Authorization Line: 1-800-867-6564
Prior Authorization Fax: 1-800-977-8226
Customer Service/Members: 1-800-606-3604 or 1-800-949-0166
back to top of page
HealthSpring
HealthSpring Website
Formulary Page
Prior Authorization form
Prior Authorization Line: 1-800-331-6293
Prior Authorization Fax: 1-866-845-7267
Customer Service Line: 1-888-299-3582
Members Line: 1-800-331-6293
back to top of page
Humana (Humana Standard)
Humana Website
Humana
Formulary Search Tool
Forms:
Coverage Determination Form (CMS Standard)
Prior Authorization Form
Prior Authorization Line: 1-800-555-2546
Prior Authorization Fax: 1-877-486-2621
Customer Service: 1-800-706-0872
Members: 1-800-281-6918
back to top of page
Medco Medicare Prescription Plan (Value)
Medco Website
Exceptions Request form
Formulary Search Tool
Prior Authorization Line: 1-800-935-6103
Customer Service/Members: 1-800-758-4531
back to top of page
Prescription Pathway
All members who were in a Prescription Pathway Plan in 2008, and did not move themselves into a different plan
for 2009, were automatically moved to a Silverscript Plan. Please refer to the Silverscript
information below.
RxAmerica (Star Plan)
RxAmerica Website
Comprehensive Star Plan Formulary (.pdf)
Standard Forms
Exceptions / Prior Authorization Line: 1-866-549-0991
Exceptions/Prior Authorization Fax: 1-866-855-2676
Customer Service: 1-877-279-0370
Members: 1-800-429-6686
back to top of page
SilverScript
SilverScript Website
Silverscript Formulary
Click on "Abridged Formulary" (for .pdf listing) or "Drug List Look-Up" (to search for covered drugs)
Coverage
Determination Form
Exceptions and Prior Authorizations: 1-800-294-5979
Exceptions Fax: 1-866-884-9475
Customer Service: 1-866-552-6106
Members: 1-866-235-5660
back to top of page
UniCare (Medicare Rx Rewards)
UniCare: MedicareRx Rewards Website
Formulary: Members will need to call customer service and providers will need to call the provider line to check
the coverage of drugs.
CMS Standard Form
Appeals and Exceptions Fax: 1-800-204-0015
Prior Authorization Line: 1-800-203-0267
Customer Service: 1-866-892-5334
Members: 1-800-928-6201
back to top of page
United Healthcare: AARP Medicare Rx Plan (Preferred Plan, Saver Plan)
AARP Medicare Rx Plan Website
Look up drug coverage through the
Search
Tool
Comprehensive Formularies (.pdf files):
Preferred Plan
Saver Plan
Medication Prior Authorization Request Form
Prior Authorization Phone: 1-800-711-4555
Prior Authorization Fax: 1-800-527-0531
Customer Service: 1-866-255-4835
Members: 1-888-865-5575
back to top of page
Universal American (Community CCRx)
Community CCRx Website
Physician/Pharmacy Support Line: 1-866-684-5395 or TTY/TDD 1-866-684-5351 (Mon. – Sat. 7:00am to 10:30pm ET)
Formulary Search Tool
Link to Comprehensive Formulary and Addenda
Forms can be found by looking up the coverage of specific drugs under the search tool, by contacting
Legal Services for the Elderly 1-877-774-7772, or by calling the Community Care Rx Prior Authorization Line (below)
Exceptions/Prior Authorization Line : 1-866-316-6049
Appeals and Exceptions Fax: 1-866-868-0858
Customer Service/Members: 1-866-684-5353
(TTY/TTD) 1-866-864-5351
back to top of page
WellCare (Classic Plan, Signature Plan)
WellCare Website
Physician/Pharmacist Number: 1-866-800-6111 option 2, TTY/TDD 1-888-816-5252, Monday through Friday
7:00 a.m. – 10:30 p.m. EST
WellCare Formulary Search Tool
Comprehensive Formularies (.pdf files):
Classic Plan
Signature Plan
Coverage Determination
Form
Appeals Fax: 1-866-388-1766
Exceptions Fax: 1-866-388-1767
Phone Number for Expedited Appeals and Exceptions: 1-800-960-2530, extension 4002
Customer Service/Members: 1-888-547-5252
(TTY/TTD) 1-888-816-5252
back to top of page
MaineCare Member Services: 1-800-977-6740
The MaineCare site has MaineCare/DEL
Formularies and Prior Authorization Forms (not Medicare Part D).
The CMS website has a
standard form for coverage determinations under Medicare Part D, together with
instructions for completing the form.
